S3340 The Cryptic Lymphoma

Introduction: Primary Pancreatic lymphoma (PPL) is a rare condition accounting for approximately 1% of all extra nodal lymphomas. It presents as a solitary pancreatic mass and can mimic pancreatic adenocarcinoma, neuroendocrine tumors, or pancreatitis. Most common symptoms include abdominal pain, followed by jaundice, nausea, vomiting, and rarely gastric outlet syndrome. This is a rare case of incidental primary pancreatic lymphoma in a patient who initially presented for perioperative evaluation of inguinal hernia repair. Case Description/Methods: Patient is an 80-year-old man with a past medical history of gastroesophageal reflux disease (GERD), who presented to the surgeon’s office due to concerns of bulge and discomfort in the right inguinal region. He did report worsening of his GERD symptoms but denied nausea, vomiting, epigastric pain, abdominal distension, or change in appetite or bowel habits. A computed tomography scan of abdomen and pelvis was performed as a part of preoperative evaluation of elective inguinal hernia repair which revealed a mass lesion measuring up to 8.0 × 4.2 × 7.4 cm inferior to the head of the pancreas with significant mass effect invading the third portion of the duodenum and encasement of the superior mesenteric vessels. Following computed tomography imaging, the patient subsequently developed nausea and vomiting after a few days. Tumor markers, including Alpha fetoprotein, CA-19-9, and Carcinoembryonic antigen (CEA) were within normal limits. Endoscopic ultrasound biopsy was performed, which revealed large B-cell lymphoma consistent with PPL. The patient was initiated on Rituximab, Gemcitabine, cyclophosphamide, vincristine, and prednisone. After 3 cycles of treatment, a complete metabolic response to treatment was observed on a PET scan. Discussion: This case highlights an initially latent but rapidly progressive presentation of PPL. The presentation is unique as the patient did not present with the commonly reported manifestations of PPL, which include epigastric pain, jaundice, and weight loss, but only experienced vague symptoms of reflux. Also, worsening of existing gastroesophageal reflux disease symptoms requires further imaging and should not be ignored. It also highlights the inclusion of PPL as a differential diagnosis in the evaluation of a pancreatic mass.